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PENGKAJIAN ASUHAN KEPERAWATAN MATERNITAS PADA PERIODE INTRANATAL

Nama Mahasiswa: ...................................................................................Nomor Mahasiswa: ...................................................................................Tanggal pengkajian: ...................................................................................Tempat Praktek: ...................................................................................Tanggal Praktek: ...................................................................................

DATA UMUMInisial Klien: ...................................................................................Umur: ...................................................................................Pekerjaan: ...................................................................................Pendidikan Terakhir: ...................................................................................Suku bangsa: ...................................................................................Status perkawinan: ...................................................................................

Nama Suami: ...................................................................................Alamat: ...................................................................................Pekerjaan: ...................................................................................Agama: ...................................................................................Pendidikan terakhir: ...................................................................................

DATA UMUM KESEHATAN1. Tinggi / berat badan...cm/ kg2. Berat badan sebelum hamil .....kg3. Masalah kesehatan khusus 4. Obat obatan 5. Alergi (makanan / obat-obatan / bahan tertentu ..............................6. Diet khusus .............................7. Menggunakan alat bantu : gigi tiruan / kaca mata / kontak lensa / alat dengar, lain-lain, sebutkan 8. Frekuensi BAB .. kali/ hari, masalah ..9. Frekuensi BAK . Kali / hari, masalah ..10. Kebiasaan waktu tidur .DATA UMUM MATERNITAS1. Kehamilan sekarang direncanakan ( ya/tidak) : 2. Status Obstetrikus : GP.A.. Usia kehamilan.3. HPHT . Tafsiran partus ..4. Jumlah anak dirumah .

NOJenis KelaminCara lahirTempat persalinan dan penolongBB lahirKomplikasi selama proses persalinanKeadaan saat iniUmur

5. Mengikuti kelas prenatal ( ya / tidak ) 6. Jumlah kunjungan selama kehamilan ini 7. Masalah kehamilan yang lain ..a. Trimester I..............................................................................................................................................................................................................................................................................................................................................................b. Trimester II..............................................................................................................................................................................................................................................................................................................................................................c. Trimester III..............................................................................................................................................................................................................................................................................................................................................................8. Masalah kehamilan sekarang 9. Kontrasepsi yang pernah dipakai dan masalah yang pernah dialami selama penggunaan alat konterasepsi ini . ..Rencana KB setelah kehamilan ini ...................................................10. Makanan bayi sebelumnya ASI / PASI ..11. Pendidikan kesehatan yang ingin ibu dapatkan selama perawatan (Lingkari tanda didepan opstion) Relaksasi pernafasan Manfaat ASI dan cara menyusui yang baik Senam nifas Metode KB Perawatan perineum Perawatan payudara

Setelah bayi lahir siapa yang diharapkan membantu : suami / teman / orang tua atau yang lain Masalah persalinan yang lalu

RIWAYAT PERSALINAN SEKARANG

1. Mulai persalinan (konmtraksi / pengeluaran pervaginam ) : tgl /jam...........................................................................................2. Keadaan kontraksi (frekuensi dalam 10 mnt,lamanya , kekuatan )...........................3. Frekuensi dan kekuatan denyut jantung janin ..x/ mnt4. Pemeriksaan fisik :Kenaikan BERAT BADAN selam kehamilan .kgTanda vital : TD = mmHg ; Nadi = ..x /mnt ; suhu = C; P= x/mnt Kepala / leher..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .................................................................................................................................................................................................................................................................................................................................................................

Dada (jantung, paru-paru)..................................................................................................................... ..................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................. Payudara.................................................................................................................................................................................................................................................................................................................................................................. Abdomen (secara umum dan pemeriksaan)..................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................... Kontraksi.................................................................................................................................................................................................................................................................................................................................................................. DJJ............................................................................................................................................................................................................................................................................................................................................................... Ekstrimitas (edema / tidak)................................................................................................................................................................................................................................................................................................................................................................. Refleks..................................................................................................................................................................................................................................................................................................................................................................5. Pemeriksaan dalamJam pemeriksaanOlehHasil

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6. Ketuban (utuh / pecah ) jika sudah pecah tgl /jam ..Warna ............................................................................................................................................................................................................................................................................................................................................................................................

7. LaboratoriumTanggal dan jenis pemeriksaanHasil pemeriksaan normalInterpretasi

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Terapi yang diberikan

TanggalJenis terapiRute terapiDosisIndikasi terapi

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DATA PSIKOSOSIALPenghasilan keluarga setiap bulan : Rp Bagaimana perasaan anda terhadap kehamilan sekarang ............................................................................................................................................................................................................................Bagaimana perasaan pasangan anda terhadap kehamilan sekarang ............................................................................................................................................................................................................................................Jelaskan respon sibling terhadap kehamilan sekarang .......................................................................................................................................................................................................................

LAPORAN PERSALINAN

Kala ITanggalJamHasil Observasi

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ANALISA DATANama klien:......................................................................................................Umur:......................................................................................................

No.Data (Symptom)Penyebab (Etiologi)Masalah (Problem)

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IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGANNo.Dx KepWaktuTgl/jamTindakanTTWaktuTgl/jamCatatan Perkembangan(SOAP)TT

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Kala 2TanggalJamHasil Observasi

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Keadaan Umum bayi baru lahir Berat badan: Panjang badan: Lingkar kepala: Lingkar dada: Lingkar perut: Lingkar lengan atas: APGAR SKORNoTgl/JamKarakteristik yang dinilai1510

Denyut jantung

Pernafasan

Refleks

Tonus otot

Warna kulit

Total Menit 1 :Menit 5 :Menit 10 :Kesimpulan :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................3. Kala IIITanggalJamHasil observasi

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Kala IVTanggalJamHasil Observasi

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ASUHAN KEPERAWATAN

TanggalJamDiagnosa keperawatanTujuanIntervensiImplementasiEvaluasi

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